Defense Support of Civil Authorities (DSCA) Ebola Response Efforts and Considerations
The 2014 Ebola epidemic is the largest in history, affecting multiple countries in West Africa. U.S. Northern Command (USNORTHCOM), as the Department of Defense lead for coordinating defense support of civil authorities (DSCA) in the United States, was given the mission to stand up a joint medical support team (MST) to assist U.S. civilian hospitals to treat patients with Ebola and prevent the further spread of this epidemic. This was based off the October 19, 2014 request for assistance (RFA) from the Department of Health and Human Services (DHHS).
U.S. Navy Commander James Lawler, Naval Medical Research Bio Defense Chief of Clinical Research, briefs the 30 person joint service Medical Support Team as part of the weeklong training hosted by U.S. Army North (Fifth Army), JBSA-Fort Sam Houston, Texas.
U.S. Army North (Fifth Army) (ARNORTH), USNORTHCOM's Army component coordinated the training of the 30-person MST consisting of health care providers from across the nation representing the Army, Navy and Air Force. Training began at Fort Sam Houston, Texas on October 22, 2014, and was completed October 27, 2014. A second group of military healthcare providers was trained in November to facilitate rotational support to the MST. The MST was designed to address multiple aspects of Ebola treatment such as facilitating additional training, serving as an interim staff while the existing staff is receiving additional or refresher training, augmenting staff treating Ebola patients and serving as a trained surge capability to deploy anywhere in the homeland.
The multiagency training effort included USARNORTH's Civil Support Training Activity (CSTA), the U.S. Army Medical Research Institute of Infectious Disease (USAMRIID) and Naval Medical Research Directorate doctors selected for the MST. USAMRIID deployed instructors to train the team on donning and doffing personal protective equipment, a critical component of ensuring healthcare provider safety while treating Ebola patients. Additionally, eight CSTA subject matter experts evaluated the MST during their scenario-based certification exercise. U.S. Army Medical Command, in conjunction with the USNORTHCOM surgeon, was instrumental in providing a training syllabus and coordination among other MEDCOM and joint agencies.
While the MST support to DHHS for Ebola virus disease (EVD) response ended on December 18, there were several relevant emergency management and public health implications that emerged as a result of this RFA and MST training.
National Readiness for a No-Notice Bio Event
Prior to the DHHS RFA in support of the EVD response effort, DoD did not have a pre-existing MST capability that was staffed, trained and equipped to the extent required for a national EVD response. DoD developed this capability in response to the RFA. This involved extensive resources, training and fielding of specific personal protective equipment (PPE) within a very short timeframe. This RFA demonstrated the need for response capabilities that could be tailored and equipped to address multiple types of infectious diseases and other chemical, biological, nuclear, radiological (CBRN) events. Additionally, a natural outbreak would require more public health and medical response while a biological weapon would involve more consequence management.
Other key considerations noted the speed of transmission due to modern transportation. Today’s diseases can easily travel across cities, states, countries, and continents within hours. Rapidly emplaced mitigation measures are critical to slowing the spread of transmission. Ongoing enforced protocols, training and appropriate PPE enable the healthcare community to stay safe and effectively treat infected personnel. Identifying gaps related to facility capabilities, staff training and PPE are critical to managing patients with a deadly, highly infectious pathogen.
Collaboration, coordination of efforts and sharing of information is critical to leverage the response effort. This was witnessed by the combined efforts of several entities in staffing, resourcing, training and equipping the MST. It was also evident in the evolving PPE guidance that resulted from information shared from the field, and across healthcare facilities, organizations and agencies.
Personnel Protective Equipment (PPE) and Training
Personal protective equipment is a general term and situation dependent. The EVD response required specific PPE and as more EVD research and real world empirical data evolved, so did the PPE guidance. The numbers, types and properties of PPE items will differ depending on the agent, the mission and the working environment. The PPE for the MST was tailored for medical staff that would work in a clinically controlled, isolation supported, hospital environment. Remote and external working environments, such as the EVD response in Africa require PPE specifically tailored to address austere conditions with limited resources and reduced capabilities. Austere conditions could also emerge following disasters and complex catastrophes, greatly impacting the working environment and required PPE.
Above left and above: A Medical Support Team augmentation class trains on JBSA-Fort Sam Houston, Texas, Nov. 18, 2014. Medical Support Team receives training on how to use Personal Protective Equipment and proper procedures when working in areas contaminated with the Ebola virus. The class was part of a weeklong training hosted by U.S. Army North (Fifth Army)
During the MST training, it became clear that clinical-grade PPE was not nationally readily available in sufficient quantities to support post event supply operations. Health care facilities across the nation were ordering PPE in anticipation of potentially receiving EVD patients in the United States while the EVD support in Africa also placed a high demand on PPE. Key implications of this PPE high demand/short supply emphasized prioritization of who gets the equipment, how it is stored and maintained and the amount of contingency stock required to support continuous operations.
Additionally, healthcare providers require effective training and validation on properly donning and doffing PPE as well as performing procedures while in PPE. Most healthcare providers are not as proficient with these PPE procedures unless they are a part of their daily scope of duties. Considerations for sustainment training and recertification are also essential due to the nature of the military environment and high turnover of rotating personnel in assignments.
While new and invasive diseases will continue to emerge and challenge the emergency management and public health environment, the development and training of the MST provided substantial insight to supporting a national bio-threat response. The Army's efforts to support its federal interagency and nongovernment partners are essential for unity of effort and maximizing response time in the nation's time of need. Development and training of the DOD MST supports this whole of government approach, which is vital for leveraging resources across the nation in preparing for, protecting against, responding to and recovering from all hazards and threats in the homeland.
U.S. Navy Commander Ryan Maves of Infectious Disease and Critical Care Medicine, Naval Medical Center, San Diego, goes over ultrasound techniques during the Medical Support Team augmentation training at the San Antonio Military Medical Center (SAMMC) on Joint Base San Antonio, Texas, Nov. 19, 2014.
Point of Contact:
LTC Maelien Shipman
MPH, CEM, DMHA, MCP
Office of the Command Surgeon, US Army North (USARNORTH)